24C-093 (2) 61 MASSASOIT ST BP-2019-0217
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma-pBl«k 24C-Ova CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit. Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv:INSULATION BUILDING PERMIT
Permit# BP-2019-0217
Proiect4 JS-2019-000354
Est Cost:52100.00
Fee_ 565.00 PERMISSION IS HEREBY GRANTED TO.
Const.CIMS: Contractor: License:
Use Groum ENERGIA LLC 92540
Lot Size(sp.fl.): 5009.40 Owner: DUBECK BARBARA G WEINER C/O BARBARA&MARK DUBECK
Zoning;URB(100) Applicant: ENERGIA LLC
AT. 61 MASSASOIT ST
AJMlicant Address: Phone: Insurance:
242 SUFFOLK ST (413)322-3111 WC
HOLYOKEMA01040 ISSUED ON:8/21/2018 0.00:00
TO PERFORM THE FOLLOWING WORK INSULATION TO SLOPES CELLULOSE
KNEEWALL RIGID BOARD
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D,P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/21/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
Department use only.
City of North mpt IT ter W d:
Building Dep rtm t AUG 1 7 201 Permit
212 Malin reef Availaeeiy
Room 1 0 near.oc omtolrvr;wsP Availability
Northampton, '010
Mao Structural Plana
phone 413-587-1240 Fax 413-587-1272 Rotfste Plans'
Other Specify
APPLICATION TO CONSTRUCT, ALTER REPAIR, RENOVATE OR DEMOLISH A ONaaE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
i/ %AMap �klqc— Lot
Unit
lVj�12 �M�U , / Zone OverlayyDlatrid71
Elm St.Dlshlc CS Diablo
SECTION 2-PROPERTYY�OWNEERRSH/IP/AUUTHORIZED AGENT
ld/ A",MA-Sd/? S%•
Name(Print) Current/ ng Atl i%—e/3 2 Z
SGE Phe K i7 if CTHo TelephoneS�
Signature
2.2 Authorized Asent:
2�2Sur�ax�/- ,yayaa� ,u�-
Name(Pnnp Cunent Mailing Atldress:
�(. /3 •322-3/x/
Signature Telephone
SECTIONS-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completedbypermitapplicant
1. Building "•) /O it Q G (a)Building Permit Fee
2. Electrical ` (l (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee n 1
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+q+5) • OO Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signatur .
BuildingC issionedinspector of Buildings Dale
= 61.,LC& eG 1AgSrt�
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be fillod in by
Building Deparlmwt
Lot Size
Frontage
Setbacks Front
Side L:-R:- L:_R:
Rear
Building Height
Bldg.Square Footage °b
Open Space Footage %
(Lot once minus bldg&paved
parking)
4o ParkiqE Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavabon, or filling)over 1 arse or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New Helms ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing E]Or Doo s 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding(O] Other[)0 --
Brief Description of Proposed
Work: SNS 4(1_471eV7a SLdWES r,6tL1-LLUSC—• Kum(-(- R(G-tit'
�' �-- 3ditKfj
Alteration of existing bedroom____Yes✓ No Adding new unfinished
bedroom Yes No
Attached Narrative Renovating unfnished basement _Yes
Plans Attached Roll -Sheet
Its.7 New house and or addition to a/xistina housing complete the following;
a. Use of building:One Family ✓ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
L Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain____Yes_No
f Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_No.
I. Seplic Tank_ CitySewer_ Private well_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERSAGENT OR CONTRACTOR APPP�LI�ES� FOR BUILDING PERMIT
I, /��f 1C�F A-ZA 1 J.MOL� r�C as Owner of the subject
property �
hereby authorize L-C;lp\
to act on my behalf, in all matters relative to work Authorized by this building permit applica' n.
SES -Pe-2R.k-T /� .lT V 8 /D
Signature of Owner �] Date
I, 7(jµ fZ,dSSXt/-CSl-E72 as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
0 S II S%Z: LES
Print Name
p/ rte/
O � U
Signature of 0 it Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (nj / Not Ap(p/l�i�ca/bnle ❑/
Name of Lleansa Holder: /`U55MA55 / v�`( O
License Numher
®�yakc
Address apralion ste
t/3 - 322-
Signatu Telephone
S.Realatered Rome 111121:12vil C r. Not Applicable ❑
Comoanv Name Registration umber
2 V 2� Sc(F�rJ[k S7 fi'dL�yprC6,
1 141-20
Address Ezpirati D to
Telephone. 3 SL�• (�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide this affidavitwill result
in the denial of the issuance of[he buitling lt.
Signed Affidavit Attached Yes....... No.__. ❑
City of Northampton
/ + Massachusetts =
s
DE'PmtMflr T OF BUILDING INSPECTIONS
212 Main Street a nicipel Building
Northampton, a 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
/�/ /fAs5A so r-T s i
(Please print house number and street name)
Is to be disposed of at:
ALL(ft wAsTE f05CS73Rew--PKb,A+-
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signaturidof Permit Applicant or Owner D,ate
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
Columbia Gas
of Massachusetts 60 Shawri Road, Unit 2 Canton, MA 02021
A MSounw Company
OWNER AUTHORIZATION FORM
1, Barbara Dubeck
(Owner's Name)
01191M. of I .. P10pulty tM6,011 at.
bi Massasoit ree
Northampton, MA 01 ORO
(Town, State, Zip)
hereby authorize VIJ(rn��(,
Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my properly. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. it is the homeowner's
responsibility to close out this permit by contacting their muuni/cipality att tthhJe completion of this work.
--2 C F. O V 2 111(�11I X/4
to/I er Signature
DJUN Q 201816 U 51gn Date
51
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
IV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Nalne (Business/Organization/Individual): Energia, LLC
Address: 242 Suffolk St.
City/State/Zip: Holyoke, MA 01040 Phone #: 413-322-3111
Are you an employer?Check the appropriate box: Type of project(required):
I.VI am a employer with_151 - 4. E] m I aa general contractor and I 6. ❑New construction
employees(Poll and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers'comp. insurance comp. insumnce.1
required.] 5. ❑ Weare a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself [No workers' comp, right of exemption per MGL 12❑ Roof repairs
insurance required]' c. 152,§t(4),and we have no 13.[]Other
employees. [No workers'
comp.insurance required.]
*My applicant that checks basal must also fill out the section below showing their workers'wmpens unni policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such.
1Conuacum,that check this bnx most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If am sub-convactors have employees,they most provide than workers'wrap.policy number.
I am"employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Guard Insurance Group
Policy#or Self-ins.Lic.#: ENWC952172 Expiration Date: 7/01/2019
Job Site Address: UI MA5,:5AS / Tf-! VE City/State/Zip:N—A&L17/.4titerfdwl A&+
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisornnenl,as well as civil penalties in the fora of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA V insurance coverage verification.
I do hereby certify andhepains and penalties of perjury that the information provided above is n e and correct.
Sinazure: fool, Dat : V/1
pie#. 413- 22-3111
Official use only. Do not write in this area,to be completed by city or town ofciat
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,acorzd CERTIFICATE OF LIABILITY INSURANCE Mrem—O I
le� arzrzDlB
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poncyges)must be endorsed. If SUBROGATION IS WAIVED,Subject to
the terms and conditions of the policy,certain poholes may require an endoreemem. A statement on this certificates does not Confer rights to the
cerWicate holder in lieu of such endorsement(s).
PROOVCER NCO9ff Mary Conroy
The Dowd Agencies, LLC PNCFAx
14 BObala Road NE .413-538-7444 AIC No:
Holyoke MA 01040 EMAIL
PR ucaa . ENELL
INSURE s PFFOROING COVEppOE Nw.
INSURE. MSURERA'Evanston Insurance Company 35378
Energia, LLC
242 Suffolk Street IxaueER e:Commerce Insurance Coma 34754
Holyoke MA 01040 IxsuRBa c:StarSlone National Insurance Com an 25496
IMSURER.:Guard Insurance Grou 8281
INSVRER E:
N URER F'
COVERAGES CERTIFICATE NUMBER:1131630225 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
FOENCTIBLE
TYPE OF INSURPNCE L OR POLICY NUMBER P p VER PoI AEYNYN EXP 11MIT9
L LMBILM 2DB4ANR ]`iO018 71112019 EACHOLCURRENCE 1%':0-7-
MIS
MERCIAL GENERAL LIABILITY p Ea
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GENEMLAGGREGATE S&OOOO]0
GGREGpTE LIMIT APPLIES PER' PRONUCTS-COM".1AGG :1 i2 ZICY X PRO- LW 3BILE LIABIVIY MOPBJ "QEl. 111,2018 COMBINED SINGLE LIMIT5(E.erclMml PUTOa'JDLY INJURY(Perperwn I 'OWNEOAUTO$ BODLYNJURY(Ptt exlEMil 4
HEDULED pU(OSPROERttOPMPGEED AIROSNAWNENAVTOSBRELLA LIAR X OCCUR ]5]50Ni WAU ]11,2018 ]1112019 EACx OCCURRENCE 31OAW]ESS WB CLAIMS-MADE AGGREGATEWCTIBLE 3
RETENTION $
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AND EMPLOYERS'ONUNUN
ANY PROPRIETORPARTNERIG"CUTIVE Y❑ NIA ELEACHACCIOENi 81,ro0,OW
OFFIGERMEMBER EXELUOEoi
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NESCRIPTION OF OPERATIONS ENav El d$EASE-POLICY LIMIT S
ME lPTIUNOFOPEM MSILOCATIONS1VEMICLESIAMCa ACORO101,Atl.Mmel RamerMBgledula,ffmmspxw Is RWB I
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
To IrVllom It May Concern AUTNORMED REPREESENTAPVE
/ YYP/ /
®1988-2009 ACORD CORPORATION. All lights reserved.
ACORD 25)2009109) The ACORD name and logo are registered marks of ACORD
® C
omm
o
nwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Construction Supervisor
CS-092540 Expires: 09/02/2019
THOMAS BROSSMASSLER
100 MAIN STREET
HATFIELD MA 01038
s:
Commissioner
./. Ynuun..r....///../ //.......
h - Choice of CavaamerARtiv&Business Regulation License or registration valid for individol use only
'. 't;�"}`�yNOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
:• T. ,(tegistnstion: 165169 Type: Office of Consumer Affairs and Business Regulation
Expiration: 1/11/2018 LLC 10 Park Plan-Suite 5170
11p`ry�
Boston,MA 02116
ENERGIA LLC 1
THOMAS ROSSMASSLER
242 SUFFOLK STREET
HOLYOKE,MA 01040 Umlerseeretary Not valid without signature